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Doctors Debate: Should City Aid Growth in Palliative Care?

Just how far should medicine go in turning death and dying into a growth industry?

Two New York City doctors, the head of the city’s largest public hospital and a nationally known geriatrician, gently clashed on that topic Thursday at a City Council hearing to discuss how to deal with the demand for end-of-life care as the baby boomer generation ages.

The geriatrician, Dr. R. Sean Morrison, argued that the city should embark on a campaign to increase public financing and awareness of palliative care, and should model it on the Bloomberg administration’s other public health initiatives.

The city should promote palliative care consultations — by doctors who specialize in treating the dying — “the same way that we’ve done with smoking cessation and the same way that we’ve done with obesity,” he suggested at the hearing in Lower Manhattan.

But Dr. Eric Manheimer, medical director of Bellevue Hospital Center, New York City’s flagship public hospital, raised concerns that overreliance on palliative care specialists would add to the fragmentation of medicine, to the detriment of patients who are seen by an often confusing and contradictory welter of specialists.

“We’re so overspecialized, so overconsulted in this city, it’s frightening,” Dr. Manheimer said.

Asked by one council member whether palliative care consultations should be mandatory, Dr. Morrison did not reply. But Dr. Manheimer countered that doctors already had too many mandates.

He recalled that every time he used to sit down with Dr. Thomas R. Frieden, the city’s former health commissioner and the architect of many of its public health campaigns, Dr. Frieden would suggest another mandate. At the rate the city was going, Dr. Manheimer joked, doctors would be able to see only one patient a day.

Their debate came as Congress is considering whether to provide Medicare financing for voluntary consultations between physicians and patients about how they wish to be treated at the end of life. An early version of that provision in the House health care bill last summer lead to conservative accusations that the bill would set up “death panels” to ration health care.

Dr. Manheimer heaped praise on the concept of palliative care, testifying that the city’s Health and Hospitals Corporation was now providing palliative care in all 11 of its hospitals, while across the country only 30 percent of public hospitals provide the service. He said more than 4,300 inpatients had used the service in the 2009 fiscal year, up by 1,000 from the year before.

But he said that the goals of palliative care — to avoid aggressive but futile treatment at the end of life — could be incorporated into the general culture of hospitals and could be carried out by everyone from doctors to nurses to social workers.

Dr. Morrison, a professor of palliative care at Mount Sinai School of Medicine, said palliative care had been hurt by the perception that it mattered only at the end of life, and that it needed to come into the picture years before death.

But Dr. Manheimer suggested that the needs of patients — especially immigrants without family to back up their wishes — were sometimes too complex to be encompassed in a written form.

Another issue, Dr. Manheimer said, is cost. Because Medicare does not now reimburse palliative care teams for their consultations, they become a separate cost center for the hospitals that provide them.

Pallitive care is sensible and saves money. It is a choice between staying on your treatment plan or making yourself more comfortable when death is apparent but still more than six months away. If you only have your doctor and hospice to choose from, many will delay getting the advice and preparation for hospice. While one hands you off to the other, there is a lot for your family to digest.

Pallative doctors and approaches are the bridge. My FinL is fading with End Stage Renal Failure. He is on dialysis. When he can’t make it to treatment anymore, then hospice steps in. His choice, but it helps when he is told he can only have four eight ounce servings of any fluid daily to remind the clinic we and his doctors are taking a pallative approach to his care, now. If he wants another can of Sprite, he gets it. We will not torture him to pretend we are doing it in his interest. It might speed his death, but I think he’d rather die with a little Sprite than his family denying him comfort to extend his days. If I hadn’t had the doctor tell me it is OK to attend to his comfort rather than the treatment plan, I’d have lost it.

It has struck me that pallative doctors might be a way of managing my risk of living. See, I played by the old rules and put all I had into my home. I have almost zero debt, but not so great health insurance. Both my parents checked out in their early years, so observing my FinL’s end has been very enlightning.

If and when I become so ill I cannot contribute to the household income, we can spend through all our savings and then charge that debt to our home until we cannot pay anymore and then the bank takes our home at the worst possible time in our lives.

Bankruptcy judges cannot reset your encumberances on your home since Congress gave CCards the right to our single dwellings in 1995. Oh, a judge can force a bank to take a haircut on those spec houses, but the judge’s hands have been tied regarding the lowly single dwelling home owner. Just as Glass-Steagall and state authority to shut down a bucket shop (that no skin in the game unbacked betting they do in insurance with CDSs) have been eliminated, the gift of Daniel Webster to the farmer, the power of the judiciary to reset the terms of your home’s encumberences, is gone. Like the dust in the wind of our castles made of sand. Your home is the bank’s White Castle.

So, seeing the exorbitant cost of living a full life under the terms of our present health insurance system, I see that a dreadful diagnosis not only proscribes my ability to get insurance, It puts me on a long road to giving it all up to a bank. Insurance that cannot insure you, unless I buy a CDS against myself? Well, I couldn’t live for six months knowing I was destroying my family’s survival for a chance at my own.

So, why not go directly to a pallative doctor and tell them I want to screw the bank out of as much money as I can. I want to spend the least possible for the most comfortable end and I want them to parade my ash around Wall and Broad proclaiming I’m one sick chick who fought the Captain her whole life.

Otherwise, I calculate I’ll need another 10K annually just top get enough insurance to live as long as Joe. You need short-term and long-term and believe me, that long-term takes a LONG time to process, so you still need a hell of a butt cloud backing you And then pray you can always afford to pay for it. Like I used to do with my home, but we know who’s out to get that. I think I’m going out Petty style. “..Swinging…” But I doubt I can convince Hubby of my plan. he’d say we need to spend $15K.

Now I get why Ferdinand Lundberg said Insurance was the worst of Wall Streets inventions. I just thought the banks were the bums, but its the whole Captain’s crew.
Banker’s Life. Like you have one left while preparing to live forever. Right, Captain?

Ever since I have heard of palliative care, that was a number of years ago, I thought of it as something that would be beneficial – that is, if the patient and family wish to partake of such a service.
I think that is the way to go for me. Being comfortable, have treatment for pain, and if up to it, able to converse with people.
Ruth Beazer

I think Ruth Beazer #3 has it right. Two of my uncles, a friend’s mother and another’s father, all in their late eighties, were cared for at Calvary Hospital in the Bronx when they were at the end. The atmosphere was particularly comforting for other older family members and friends when they visited.

Be warned: the DEA(Drug Enforcement Administration) does not like or approve of “palliative ” care and does as much as it can get away with to arrest and prosecute doctors, as well as non MD health professionals who either participate in it, or prescribe or give “palliative” narcotic pain medication.
While New York City is relatively free of the baneful influence of too much federal nitpicking, this is only because the state laws here are already about as draconian and restrictive as is possible.
In NYC, it is the doctors themselves who have allowed specialization to ghettoize end of life care.
Most NYC MD’s will never write a prescription for a federally “controlled” substance. This forces those in need of such care to use an overtaxed and burdened system of doctors who do have the “intestinal fortitude” to to do such prescribing.
While I have heard numerous MD’s make all the right noises and state how they personally believe that all palliative narcotics should be freely available to anyone in need; these same “good” doctors would sacrifice their firstborm before they would actually write a narcotic prescription, for anyone .
This cowardice goes so deep within the practice of medicine that when nicotine gum was sold only with a prescription, most MD’s would not prescribe it because it was an addictive drug without enough controls on the user to protect them . Other doctors would not prescribe it because of an innate resentment against any prescription for a potentially addictive substance and a lpersonal distaste for any form of replacement therapies.
The average MD, even in NYC, still thinks that suffering is the right treatment and payback for people who are either smokers trying to quit, drug addicts trying to stop using illegal drugs or people who “claim” to be in severe and intractable pain.
Most doctors and many nurses , as well, hate and fear patients who need narcotic prescriptions because the medial profession has been taught, at least since the end Second World War when antibiotics were supposed to have eliminated the need for heroic analgesia, that there is no need, and never was , for narcotic analgesia and that it causes immediate and permanent addiction, making otherwise normal patients who scream in pain into patients who may ask them to prescribe for them the only medication in the pharmacopeia that actually palliates and partially controls their suffering.
When the MD’s begin to suffer like the rest of us , then they might decide to stop allowing ignorant rednecks from Washington send in federal police agencies to manage their prescribing for them.

Primary care physicians need to be there at the end of life. How can a death specialist know more about all the issues that come up during serious and terminal illness than a long time primary care physician?

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